Dr Robert W Backus (RPCV Brazil) is variously described in the West River Valley as "a saint," "a real healer," "a vanishing breed," "all medicine," and a man who "walks on water"

"With a complete sense of humor, people fondly call him 'Dr. Quackus,"' Seaton said. "Because it rhymes with' his name. But it's the furthest thing from the truth. He's one of the most excellent diagnosticians you could meet. He does walk on water. He has zero ego. If the spotlight shines on him, he diverts it as fast as he can. Everything he does is for the good of his patients. He's a man of tremendous energy. If he got a dime for every cry memorial or funeral service he went to, he'd be a wealthy man. And when he speaks, he speaks off the cuff, with no notes, from the heart, and cuts rig right to the essence of the people he's talking about."

When it comes to health care, this is a difficult time for Americans. Medical costs are skyrocketing. Hospitals have cut back on staff The price of health insurance has gone through the roof, and millions of Americans - especially children - are uninsured. For many, financial ruin is just one serious disease away. Doctors must see more patients per hour to earn a decent living and make a dent in the large debts they carried away from medical school. Doctors, too, have insurance problems: high malpractice insurance rates have chased many of them out of the field altogether. The pharmaceutical industry has developed many wonder drugs, but the cost of some is so high that people are forced to fill their prescriptions over the Internet, or in Canada or Mexico. Have I left anything out?

The family doctor with the MD license plate that allowed him - back then, doctors were usually male - to park next to a fire hydrant while he visited patients in their own homes, has turned into a "primary care physician" insulated by secretaries and receptionists and seen - very briefly - only in the office. You would think that the time of television's folksy Marcus Welby, MD, was definitely over.

Yet in Townshend, one doctor has been thriving on the practice of rural family medicine for 27 years. He still makes house calls. He frequently treats three generations of the same family and he has delivered at least one of those generations himself. He earns a good living ... for Vermont. He is the heart and soul of a small, busy and growing hospital. On weekends, he drops by the local auction or the barber shop to catch up on the latest gossip - it helps him learn who among his patients are feeling ill, so he is prepared when they show up in his office. And in his spare time, this former Peace Corps volunteer pays his own way to Brazil, where he delivers health care to people living along the backwaters of the Amazon.

He is Dr Robert W Backus of Grace Cottage Hospital, and he is variously described in the West River Valley as "a saint," "a real healer," "a vanishing breed," "all medicine," and a man who "walks on water."

"I think you're going to have a hard time finding anyone to say anything bad about Bob Backus," said Paul Harrington, executive vice president of the Vermont State Medical Society. "I know people call him a hero and a saint. Well, it's not impossible. There are still one or two of those around."

Backus doesn't enjoy comments like that - not at all. When I told him some of the things I'd been hearing about him, he growled, "There's nothing saintly about me. It's all about the patients. It doesn't have anything to do with money and everything to do with service."

In his approach to family medicine, Backus isn't alone. Luckily, Vermont is full of doctors who enjoy the challenges of family medicine. They may not, like Backus, help a patient's family trim their blueberry bushes or help an older man cut and stack his wood, but they know their patients, donate their time to free clinics, devote time to training younger doctors, and are also deeply involved in their small communities. Other areas, rural and urban, may not be so lucky.

In a time when health care is in crisis, it is instructive to took at the life of someone like Backus, who has managed to keep his practice and the hospital he loves - afloat through enough ups and downs to rival the misfortunes in that old movie serial, "The Perils of Pauline."

Backus is a small man, "midget-like," as he likes to say. At 63, he as gnarled and spicy as a piece of dried ginger. He describes himself as a "Kennedy social liberal" crossed with a "Snelling fiscal conservative."

He is frighteningly bright and outspoken. He speaks in short, brisk phrases that often fall short of reaching sentence status. Self-confident and self-depreciating, he has a dry wit and takes as much pleasure in the absurdities of human nature as he does in his patients' well-being.

Although he was born in California, came to Vermont in the 1960s, and wears Birkenstocks - all flatlander traits that are supposedly anathema to old-time Vermonters - his family's roots are solidly in Vermont.

"My family on both sides came over in the 1600s," he said. "The Walcotts, my mother's clan, founded Walcott, Vermont. The Backuses went to northern Vermont. Go up to the old graveyards and there are Backii and Walcotts planted all over the place. But if you weren't born here, you're still a flatlander."

Backus is certified in family medicine and geriatrics. When he was studying medicine at the University of Vermont, his teachers tried to direct him into cardiac surgery. He refused.

"I can imagine nothing more boring than doing a heart after a heart after a heart, and never knowing the person under the drapes," Backus said. "What the hell is that all about? Family medicine is fun, it's interesting, I would never do anything else."

Backus practices in a cozy, old-fashioned office at Grace Cottage. There's an oriental carpet on the floor, an antique doctor's table in the corner, old medical books lining the shelves, a skeleton hanging from a hook - and an up-to-date computer.

Every wall and surface of the office, from top to bottom, is covered with paintings, photos of patients, friends and family, and cartoons. Sample: two vultures on a limb are talking, and one says, "Sure, dead is important, but it has to taste good."

At one point, Backus pointed to a framed photo of a couple hanging on the wall. The man was wearing a World War II pilot's uniform; the sophisticated woman with him was wearing a fancy hat. He said, with a grin bordering on a slight leer, "That's a picture of my mother and father the morning after they made me."

Grace Cottage Hospital was started in a private home by Dr Carlos G Otis in 1949. (It was named after the wife of the man who provided the start-up money.) Otis delivered the hospital's first baby that very same night. It has grown into the Otis Health Care Center: a fivebuilding complex with an emergency room, laboratory, radiology unit, physical therapy department, pharmacy, six doctors, a psychiatrist, podiatrist, physical therapist, adult day care, a 14- bed residential care home, and an emergency medical services training center, among other things.

Grace Cottage runs on "love and pennies," Backus said. Although it has often appeared to be teetering on the brink of bankruptcy, it actually has a $14 million yearly budget, 162 full-and parttime employees, and a growing endowment that today stands at $4 million.

In the first six months of this fiscal year, its doctors had 14,000 "encounters" with patients, the hospital provided patient care for 2,130 days, and the emergency room had 1,046 visits, according to Albert LaRochelle, the hospital's CEO.

"We're what they call a 'critical access hospital,'" LaRochelle said. "It's a federal and state designation to receive compensation at a higher level based upon cost of operation. We were the first hospital in Vermont to receive that designation. I believe there are about five of them now, and probably about 1,000 in the country. All of us are in rural areas, and can have no greater than 25 beds. We're licensed for 19 beds."

Like all hospitals, Grace Cottage is funded mainly by payment for services. This can come from Medicare, Medicaid, private insurance companies or out of the pockets of its patients. When people can't pay, Grace Cottage treats them anyway.

"People have told us for years that we're an anachronism, we're a dinosaur," Backus said. "I've heard that as long as I've been here. 'You're going to go under, we're going to take you out.' We're still here. Grace Cottage is a Peace Corps volunteer's dream community development project, and it works."

From the beginning, the people of the West River Valley have donated time and money to keeping their beloved hospital running.

"Some people have been donating since the hospital started in 1949," Backus said. "Some people give a thousand, some people give one dollar. They all get a letter thanking them. Sometimes, when people die, they will their estates to us. We just had a family leave us $180,000. Very modest Vermont family, saved it up, thought we gave them good care, so they donated it."

Backus may be a country doctor, but his reach stretches far beyond Townshend. He serves, for example, as stateside chairman of the African Amazon Aid Organization.

"It is the best NGO (non-governmental organization) I've ever worked with anywhere in the world," Backus said. "Their overhead is 8 percent. That means that 92 percent of what people give goes directly to the patients. We have the only woman's health program in the Amazon. Only diabetic program in the Amazon. Only major children's program in the Amazon. It's fascinating. The politics are, of course, deadly. But I go down and volunteer in their clinic and go out on their riverboat. It's true volunteering. I pay my own way. I pay my room and board."

Since the mid-1980s, Backus and Grace Cottage have been training 'Medical students as interns. A few years ago, UVM gave Backus an award for outstanding clinical teaching.

"Dr. Backus has been an outstanding community-based faculty member for the UVM Department of Family Medicine clerkship \students and senior students," said Dr. David N Little, Clerkship Director in Family Medicine at UVM, in an email. "Students relate well to Dr Backus and his partners at Grace Cottage Hospital, where they get a chance to participate in patient care at one of the last small rural hospital systems in Vermont."

In 2003, Backus won the Vermont Medical Society's Physician of the Year Award.

"Bob is a model for me of representing the highest standards of the Vermont physician," said the VMS's Harrington. "Caring for his patients is his life, but he still finds time to make contributions to improving Vermont's health care system. Bob is also a gifted writer and philosopher. He always seems to find the way to express his thoughts as a physician who cares deeply about Vermont and its future, and brings great wisdom to any discourse."

A few years ago Backus stopped taking new patients and started planning his exit strategy. He has announced that he will cut back to half-time in 2007, and retire when he is 70. His retirement seems to be a running joke at the hospital.

"He claims to be stopping, and we're all waiting to see," said Andrea Seaton, the executive director of the Grace Cottage Foundation. "But it's hard to imagine. He's often here on his days off and vacations, and his wife knows if she wants to see him on Thanksgiving, she may well have to bring Thanksgiving dinner here."

[Excerpt]

The Experiment

Backus went to college at the University of Nevada in Reno. When he was 20, a history professor thought he might be adventurous enough to go abroad for a homestay. So he proposed Backus to The Experiment in International Living (now called World Learning, Inc) in Brattleboro. He was accepted and spent three months with a family in Brazil, learning the culture and language. The experience changed his life.

"Came back, finished my senior year, went into the Peace Corps and went back to Brazil," Backus said. "The Alliance for Progress, which was John Kennedy's thing, was sending a lot of surplus wheat, cheese, peanut butter and milk down to Brazil, which was supposedly used in school lunch programs. One of our jobs was to make sure it actually got where it was supposed to go, which sometimes was a little difficult. Sometimes we were living in mud huts with 500 mosquitoes over our heads every night."

In early 1965, Backus's father had a stroke and he returned home to California to help his family. He also started taking pre-med courses and looking for work. The Experiment offered him a job working on Peace Corps training programs for Brazil, so after his father recovered, he headed East.

"The day I drove into the state I felt that I was home," Backus said. "I was with an old Peace Corps buddy, and we came over Skyline and stopped and had a cup of coffee. And I said 'This is heaven. This is home'."

While working at the Experiment, Backus met his first wife, former Vermont State Senator Jan Backus, the daughter of Jack Wallace, the founder of the School for International Training. The pair were married in 1966. Soon afterward, in 1967, Backus was back in Brazil running training programs for the Peace Corps. The couple's first daughter was born in Brazil. (They have three daughters. They were divorced in 1991, and in 1995, Backus married Caroline Bishop, a special education teacher at the Dover elementary school.)

The couple came back to the States in 1970. As Backus took more pre-med courses at the University of Massachusetts, he often worked three or four jobs at once. He was on the Rescue Squad in Brattleboro, and worked as a diener - someone who takes organs out of dead people - for the pathologist at Brattleboro Memorial Hospital; he was also an orderly there.

Then Backus got into medical school at UVM, financing his studies with government grants and family money.

"In med school in those days, you only ran up about $60,000 or $70,000 in debt," Backus said. "I finished early. I didn't take any vacations."

Backus did his residency in the Adelaide Children's Hospital in Australia.

"I said to Jan, 'You've been following me around, so where do you want to do the residency?'" Backus said. "She said, 'How about Australia?'"

When the family came back from Australia in 1978, Backus starting talking with Otis about working at Grace Cottage.

"He said, 'What do you want to earn?'" Backus said. "I said 'I have no idea. I've been out of the country for a long time. Do you want me to go and find out for you what it's worth?' He said, 'Sure, go ahead.' So I came back and said, 'Well, the average family doc is making about $30,000 to $35,000 in Vermont, with health care benefits starting.' He said, 'That's great, $15,000'll be just fine.' I said, 'I said $30,000 per year. That's $15,000 for half a year. You want it or you don't want it?

And he looks at me and says, 'Yeah.' He would have taken me for nothing if he could, that old sharp shooter. And we got along pretty well after that."

Backus worked with Otis for six months, then did another two- year residency at UVM. Then he joined the staff of Grace Cottage, and has remained there ever since.

[Excerpt]

Doctoring Dangers

Over the course of his career, Backus has been sued for malpractice four times.

"Two times weren't even cases, I was standing in the way and they were using me - people were trying to get to someone else," Backus said. "Those cases were dismissed. Two times, I felt I had responsibility. I went straight to both patients and told them right up front. And I told the lawyers for the insurance company, which did not please them. Actually, in one case I had to hire a lawyer to look over the insurance company's lawyers' shoulders to make sure the plaintiff - the patient - got what they needed out of my pocket. Because that was the right thing to do."

As a result of one case, Backus changed his office systems to prevent similar mistakes from happening in the future.

"Systems break, even though they look really good," he said. "Even though you build what looks like a perfect system to track stuff, there's always an Achilles heel. So now, when I build systems, I kick the hell out of the tires."

The other suit was the result of an obstetrical case.

"I learned you don't take other doctor's cases," he said. "If you're a family doctor doing your own deliveries, you know your own people and you don't screw up. Get somebody you don't know lumped on to you, that's where you have problems. So I learned two very important lessons."

It hurts, Backus said, when he has to tell a patient that he's made a mistake.

"The biggest and most important thing I learned back in the beginning was if I did something that was not right, or I missed something, I always tell the patients," Backus said. "Never held back. It's hard to do. Tears in your eyes when you tell them. They trusted you. You feel you failed them, yourself, your profession, the hospital. And then you figure it out. Sometimes the patients help you."

As a result, his patients seem to adore him.

"With a complete sense of humor, people fondly call him 'Dr. Quackus,"' Seaton said. "Because it rhymes with' his name. But it's the furthest thing from the truth. He's one of the most excellent diagnosticians you could meet. He does walk on water. He has zero ego. If the spotlight shines on him, he diverts it as fast as he can. Everything he does is for the good of his patients. He's a man of tremendous energy. If he got a dime for every cry memorial or funeral service he went to, he'd be a wealthy man. And when he speaks, he speaks off the cuff, with no notes, from the heart, and cuts rig right to the essence of the people he's talking about."

Fixing the System

Backus served as medical director of Grace Cottage from the mid1980s until just recently. He knows from first-hand experience the difficulties of running a hospital today.

"The paper load that I see now is daunting," Backus said. "I sign hundreds of useless pieces of paper every week. It's all about asscovering, and it's a huge waste of time. Dealing with all these insurance companies is a huge waste of time."

Many of his patients lack health insurance.

"All my small-business people have the same problem," Backus said. "All my young people who are working in the woods, they do, too. They don't have any insurance. Nothing. They can't afford it. It's big bucks. It's five grand a year, and for someone who only makes fifteen, it's a third of that person's income - before taxes. This country can do better. These are people who pay their taxes every time. They go out and fix the road instead of waiting for the road crew to come. Real hard-core Vermont folks living in poverty. That's wrong."

As a Kennedy liberal and Peace Corps volunteer, it should come as no surprise that Backus supports the idea of universal health care. The surprise is that he also supports the idea of attaching to it a benefits package that would limit some of the current excesses in health care. "Single-payer, I don't care who the payer is, but a single- payment mechanism to reduce all the bureaucratic crapola, so we're not dealing with 1,500 insurance companies across the United States," Backus said. "Get rid of that and put in a lean benefits package that services the basic human needs of your patients, and go with it. With a good administration that holds the line. But you're going to have to raise taxes on people like me. We that have more income should pay more taxes. And thems who ain't got no money shouldn't have to pay any taxes. And I've been saying it since 1972. And I have not seen anything to change my mind."

In the mid-Eighties, for the Vermont Medical Society, Backus chaired a statewide commission that developed a benefits package for the state.

"I got together doctors from all spheres - psychiatrists, surgeons, obstetricians, internists, all of them," Backus said. "We had some great lengthy meetings. We developed the first basic benefits package proposal, which we called 'Bud,' as in Budweiser. The second proposal was called 'Bud Lite,' because our first proposal was too expensive."

The package represented "basic, good-quality health care for Vermonters," Backus said. Blue CrossBlue Shield priced it out and said it was too costly, but according to Backus, it would compare well with the costs of basic services today.

"You need a yearly exam, you need your mammograms when you need them, when your cholesterol is too high you need medication to take it down when you can't do it through diet and exercise," Backus said. "You need something if you're hypertensive, and if you have a heart attack or a stroke or get renal failure, you need to be treated for that. If you fall down at home and break your leg, you need to get in an ambulance and go to the ER if you can't travel by car. All that stuff is easily provided for if you have a system that's well-run."

The key, Backus said, is that the system must be run by well- trained bureaucrats who have the patients' needs at heart. If it is run by run-ofthe-mill bureaucrats, the care will be run-of-the-mill- and more expensive.

"So a lean benefits package for everyone in the state is important, administrated by the state," Backus said. "If you had one, you wouldn't be able to get an MRI if you had a headache. You would have to have neurologic findings or a significant family history or a significant worry on the part of your physician. Now, with Medicaid, if you walk in and say 'I've got a headache, , you get an MRI."

With a basic benefits package, doctors would have to really examine a patient.

"If the guy has a headache, you've got to find out what brought it on," Backus said. "'How long have you had it?' 'Couple of weeks ago."Anything happen a couple of weeks ago?' 'Yeah, my father shot my mother.' 'Oh, really? You think that might contribute to it?' You've got to take a history. You've got to rule out. If I just sit across my desk and write out an order for an MRI, it's twice as fast and I charge you the same."

Many politicians claim that universal health care would lead to the rationing of medical treatment. But rationing already exists, Backus said.

"We're denying 46 million people health insurance," he said. "That's rationing right there. And that's the ones who have no insurance. Look at the ones who are partially insured. That's another what? 60 or 70 million? One-third of our whole country has crap for insurance. What's the most common reason for people going bankrupt right now? Health care bills."

Governor James Douglas, who does not support a single-payer system, recently suggested cutting payments to doctors and hospitals as a good way to cover a Medicaid shortfall- His proposal angered Backus.

"It's just wrong," Backus said. "The average specialist in Vermont is getting paid today what he was getting paid in 1994 or 1995, but his malpractice insurance has gone up umpteen percent. His overhead costs have gone up umpteen percent. An\d they're going to cut him? They're going to take him from 49 cents on the dollar to 43 cents on the dollar? They were trying to recruit a new orthopedist for Bennington, and a guy said, 'I'm not coming here. I can't make any money.' There's your specialist guys going. Bring a family physician into Vermont and tell him the starting salary is $90,000 to $100,000 and they laugh in your face. They can go to Iowa or something and make $150,000 with full bennies, and do less work. Does that tell you anything? Thus starteth the brain drain, sayeth Zarathustra."

Government out of the Bedroom

The introduction in Vermont of legislation to support physicianassisted suicide has sparked widespread discussion in the state. Backus's position is clear: It is a matter for the physician, the patient and the family - and no one else.

"It is not an area where the government should step in," Backus said. "It's a private family affair. We don't need to legislate that stuff. All I'm saying is one statement: keep the government out of that business. They have no room to move in it. It's not their turf. It's like people talking about people's sex lives. Do I give a damn if somebody's gay or not? Whatever they do in their bedrooms is their own damn business. That's what my ancestors fought for. My father went to war for it. It's no one's damn business. It has to do with people's rights to be themselves, as far as I'm concerned."

Future

Backus stopped taking new patients a few years ago, and in 2007, he plans to cut back to half-time. He wants to continue working as a volunteer doctor in the Amazon, and, if that is not financially feasible, to volunteer somewhere else in the U.S.

"I don't have a pension here," he said. "A 401(k) appeared about three years ago. So I have to be careful about doing the overseas work. But I'll volunteer somewhere. There are parts of America that don't have a doctor. It's giving back. You give until you can't give any more. You get a hell of a lot back that way, too. I've been given this blessing, and it's time to give back."

Backus sees his retirement as a way to protect his ego from being "too big a fish in a small pond." It also provides more opportunity for the younger doctors at the hospital.

"I've already started handing over patients I've delivered, and their parents, who are still in the 50-year category, and they're doing fine," Backus said. "My colleagues are probably spotting stuff I've been missing all these years. My older patients want me to stay around a little more, but at age 70 I should be done practicing medicine as a full-time or part-time physician. Here. If I still have the brains and the money, I'll keep doing it. I get a little teary sometimes, but that's the graceful way to be, and it's important to have grace. I want to leave here the same way I came in. Quietly. A bag in my hand and a wave good-bye."

It will be "a rude awakening" for the West River Valley when Backus finally retires, said CEO LaRochelle.

"People really don't understand what they're going to be losing when he does decide to hang it up," LaRochelle said. "He and Dr. Otis are a vanishing breed. They were all medicine. I'm not sure we will ever be able to replace them."

Copyright Boutin-McQuiston, Inc. Jun 01, 2005

When this story was posted in July 2005, this was on the front page of PCOL:

The Peace Corps LibraryPeace Corps Online is proud to announce that the Peace Corps Library is now available online. With over 30,000 index entries in 500 categories, this is the largest collection of Peace Corps related stories in the world. From Acting to Zucchini, you can find hundreds of stories about what RPCVs with your same interests or from your Country of Service are doing today. If you have a web site, support the "Peace Corps Library" and link to it today.

July 8, 2005: PC suspends program in GabonPeace Corps announced the suspension of the program in Gabon citing the high cost of the program. In addition, a 2003 Inspector General report documented safety and security costs of $1 million that would be necessary to keep the program operating successfully. Background: In 1998 Peace Corps Volunteer Karen Phillips was was found murdered in the weeds about 100 yards from her home in Oyem, Gabon. Her killer has never been brought to justice.

Friends of the Peace Corps 170,000 strong170,000 is a very special number for the RPCV community - it's the number of Volunteers who have served in the Peace Corps since 1961. It's also a number that is very special to us because March is the first month since our founding in January, 2001 that our readership has exceeded 170,000. And while we know that not everyone who comes to this site is an RPCV, they are all "Friends of the Peace Corps." Thanks everybody for making PCOL your source of news for the Returned Volunteer community.

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